To Whom It May Concern

With growing numbers of patients accessing their radiology reports, it matters more than ever what you say — and how you say it.

Radiologists have long written reports with other physicians in mind. But as more patients gain access to their imaging reports, radiologists need to embrace this changing audience and create a new kind of impression.

It's not what you say, but how you say it. This adage may be a guiding principle for radiologists striving to create an accessible, patient-friendly report. The pros and cons of making radiology reports more available and more comprehensible to patients are hotly debated among patient advocates, referring clinicians, and health care administrators. At the heart of the conversation is how to responsibly present the information in a clear and concise report that adds value to patient care and improves outcomes.

"The ultimate goal should be to create a patient-facing report in a format that is both easy to understand and visually appealing to patients," says Arun Krishnaraj, MD, MPH, chief of the body imaging division at the University of Virginia Health system. "We believe new reports presented in this fashion will lead to improved shared decision-making and better informed patients."

Valuing the Information

Despite the necessity of radiology reports in the health care chain, when and where they become available — and whether they serve up relevant, readable, and actionable information — presents a contentious challenge for radiologists, their colleagues, and the patients they serve.

A radiology report is the final link in the imaging value chain, and it reflects the radiologist's role as a physician and expert. "These reports serve many stakeholders," says Krishnaraj. "Referring providers use them to determine next steps in treatment, and payers and administrators use them for reimbursement purposes." But for patient-centered health care, Krishnaraj points out, radiology reports can also provide patients with a better understanding of their illness and options.

Report structures typically vary according to type of exam, with clinical information and comparisons. Information usually covers the techniques used, findings, and impressions — which basically state the radiologist's conclusion, possible diagnoses, and next steps. The report is sent to the clinician who requested the imaging study, relevant images are stored digitally in a PACS, and, ideally, all members of a health care team have access to the PACS for future imaging studies.

Radiology reports still aren't available to patients through their electronic health record (EHR) patient portals at many health care facilities. Instead, patients must rely on getting a physical report from their referring physician — which may require a special request and usually takes longer to secure. But if and when EHR reports become available, 88 percent of patients surveyed said that being able to access them through their portal was very important. Likewise, 88 percent of referring physicians found it useful to release reports to patient portals.

Meeting Patient Expectations

Patients who want access to their radiology reports should have it, according to Andrea Borondy Kitts, MPH, a patient advocate and consultant for Lahey Hospital and Medical Center and the University of Connecticut Health Center, Farmington. "Everyone in medicine is always saying they want to connect with their patients," she points out. "So why not consider patients the end users of radiology reports when creating them?"

The needs and preferences of referring physicians must also be a consideration, she acknowledges. But, at a minimum, Borondy Kitts suggests, patients and physicians should be considered equally as the target audience. "If radiologists want to use technical medical terms for the benefit of the ordering physician, that's understandable. But the reality is that everybody benefits from plain language, not just the patients, because there is less of a chance for misunderstanding," she says.

Patients ultimately rely on the expertise of their physicians, Krishnaraj says. "But educated patients are better stewards of their own health care," he adds. And there are some things patients would like to see in their radiology reports. Krishnaraj has been working with fellow UVA radiologist Jason N. Itri, MD, PhD, and other colleagues to create a viable report process that's more patient-focused.

Their work to date suggests that patient-centered reports should include some basic structured components. For instance, they should have an easy-to-read format that spells out what type of test the patient has just received and in what situations that type of imaging is typically used. There should be a section that clearly states what the finding may mean, with appropriate possible follow-up options. For example, there could be a graphic showing where the findings put the patient on a scale of risk of cancer. And there would certainly be a "What's Next" section providing patient resources and physician contact information for follow-up questions and concerns.

Patients want a direct line of communication with their radiologists, Krishnaraj says. And they want their images housed in a location and format that makes them easily accessible to other physicians. He also noted that patients usually welcome the opportunity to be surveyed to provide feedback on the quality of care they received.

Redefining What's Important

Radiologists who recognize how patient satisfaction will align with value-based payment models will embrace a new standard for radiology reports, says Krishnaraj. "We will be justifying our contributions to care to be paid accordingly," he says.

He points to the business philosophy of Amazon founder Jeff Bezos as an example of being more focused on the end user. Bezos has credited the company's success in large part to making the customer the primary reason for doing anything — from delivery to returns to providing a wealth of product information. The point he is making, Krishnaraj says, is that you have to approach everything from the standpoint of "What does the patient want?"

When creating a radiology report, "it's not just about what you want to do or about getting paid," says Krishnaraj. "You have to think about why you do your job and who benefits the most from a change in your current practices."

Of course being collegial and abiding by administrative policies is important, Krishnaraj notes. Radiologists creating a report must always consider the perils of unintentionally misrepresenting information from findings. "But at the end of the day," he says, "a patient's understanding of his or her health and all available treatment options are what define who you are as a radiologist."

Anticipating Obstacles to Change

When trying to improve the radiology report process, you should expect pushback, cautions Borondy Kitts. Some referring providers believe that a patient-focused radiology report that more clearly defines findings and treatment options could disrupt communication between themselves and their patients. Some radiologists think patients should only have access to their EHRs in the presence of a physician to avoid misunderstanding of findings.

"Patient anxiety from the misreading of information in a report is the main justification for not providing patients more useful information," says Borondy Kitts. "But I contend that having a layperson summary in the reports will actually reduce confusion and anxiety."

There are other challenges to delivering more value-added radiology reports. There needs to be a standardized method of uploading reports to EHRs and patient portals to ensure accuracy and eliminate redundancy. And radiologists must avoid generating two separate reports — with one addressing referring clinicians and the other targeting patients. Spending more time creating reports is not popular with productivity-minded hospital administrators or radiologists with a heavy workload, notes Krishnaraj.

Still, there needs to be a shift from high-volume to high-quality care, Krishnaraj says. "You can't just check the boxes and move on to the next case," he says. "That's just doing what you need to get done in order to get paid."

Building Better Reports

There are some good first steps to take when considering how to improve radiology reports with more meaningful information to benefit patients, Krishnaraj says. "Ask yourself, 'What does the patient want and what am I capable of providing?' Consider what you would want to see if you were the patient," he says. Answer the clinical question, even if one hasn't been asked. Be brief and don't repeat yourself. Be definitive, but set limitations in your explanation.

Wording is critical. Revisit terms that could be misleading before they make the final report. For example, instead of saying, "Malignancy should not be excluded" in a report, note that other non-malignant possibilities "are favored." Include the necessary medical jargon (hypointense, low attenuation) only in the findings section of your report, not when reporting impressions.

Dig into the patient's chart and familiarize yourself with the patient's medical history. Make sure the information you rely on is integrated in real-time in the EHR. Use all available resources to avoid missing something, including previous diagnostic errors that can be learned from, Krishnaraj says. Explore readily available tools, like ACR Assist™, and integrate ACR guidelines on report writing into your practice.

While creating your report, consider the imaging process as a whole — from the study to the waiting room to the follow-up consultation, says Krishnaraj. A more patient-minded radiology report is a vital component in positive collaboration with referring physicians and critical to trusted communication with patients and their families.

"The radiology report is the core product of your work in imaging," Krishnaraj believes. "Double down on your experience. Your report can achieve a lot of goals at once, and it is the end result by which radiologists will be judged."